Endoscopic Forehead Lift

44.1 Forehead Aging Process

The aging process is characterized by a progressive loss of firmness and elasticity of the soft tissues of the face, compounded by the pull of several vectors on the tissues [1]. This process is particularly evident in the upper third of the face, leading to changes in eyebrow and lid position that give the person a tired and aging look. Tissue descent results not only from the effects of the pull of gravity but also from the persistent action of the corrugator (corrugator supercilii), procerus and orbicularis (orbicularis oculi) muscles which act as eyebrow depressor. On the other hand, the frontalis muscle loses its ability to elevate and maintain forehead structures in position (Fig. 44.1).

This muscle group is also responsible for the horizontal lines of the forehead, the vertical glabellar lines, the horizontal radix lines, and the radiated periorbital lines creating the well-known “crow’s feet.” Lines that appear only during muscle activity are considered “dynamic” and may become “static” or permanent

J. Espinosa ( )

ENT Service, Universidad de la Sabana: Campus Universitario del Puente del Común, Km. 7, Autopista Norte de Bogotá, Colombia and Faculty of the Integrated Otolaryngology Service,

Central Military Hospital, San Rafael Hospital Clinic, Universidad Militar Nueva Granada, Calle 123 # 7–60, Consultorio 304, Bogotá, Colombia

e-mail: jorgespinosa@gmail.com

J.R. Reyes

Colombian Society of Facial Plastic Surgery and Rhinology, Av. 7 # 119-14, Consultorio 211, Pontificia, Universidad Javeriana, Av 7 No 40-32, Bogotá, Colombia

e-mail: joserafaelreyes@gmail.com

when there is damage to the deep layers of the skin due to repeated muscle contraction (Fig. 44.2).

Although the first reports about modern facial lift date back to the earlier part of the past century with the work of Miller in 1907 [2], the forehead and brow area began to receive similar attention only in the mid twentieth century [2]. It was around 1992 that a new era began with the work by Core [3], Lyand [4], and Isse [5] and with the use of optical instruments for endoscopic procedures. Thus began endoscopic forehead lift as a method for rejuvenating the forehead and the periorbital with the new ability to produce optimal, natural-looking, and lasting results with minimal, wellcamouflaged scars.

Despite the need for special instruments and a very well-defined learning curve, endoscopic forehead lift has become a most valuable tool in the rejuvenation of the forehead and periorbital area [6].

44.2 Indications

The earliest signs of aging tend to manifest in the periorbital area, particularly in eyebrow position. A tired, premature-aging look is common as a result of a lowset eyebrow tail. Although brow position and shape vary significantly depending on race, gender, and age, in general, an attractive female eyebrow should be set above the upper orbital rim and the tail should be slightly higher than the head. Starting at the tail, the brow must follow a smooth curve toward the midline and the head, sometimes with a small elevation at the point where the lateral third joins the two medial thirds. In men, eyebrows are usually horizontal in shape and are set at the same level of the upper orbital rim. Endoscopic forehead lift is indicated in young patients with a

Fig. 44.2 (a) Lines produced by the contraction of the forehead muscles, and crow’s feet lines. (b) Glabellar lines produced by the contraction of the procerus and corrugator supercilii muscles. (c) Horizontal lines produced by the contraction of the frontalis muscle

Fig. 44.3 (a) Patient with lateral eyebrow ptosis giving him a sad appearance. (b) Six months after endoscopic forehead lift

skin in fact only require repositioning of the brow in its original position, thus making blepharoplasty unnecessary, or reducing significantly the amount of skin to be resected [7, 8].

In some patients, brow ptosis becomes more pronounced after upper lid blepharoplasty, usually as a result of aggressive surgical techniques in which an important portion of the orbicularis muscle is removed with an excision that extends laterally. This creates significant scarring of the muscle that pushes the brow down and creates a stigma in the form of a pronounced wrinkle in the crow’s feet area associated with brow ptosis, resulting in patient dissatisfaction (Fig. 44.4).

The physical preoperative examination is done with the patient standing in front of a mirror. The distance from the lateral cantus, the pupil, and the medial cantus to the lower edge of the brow is measured, and asymmetries are recorded (Fig. 44.5).

Fig. 44.4 Pronounced wrinkle in the crow’s feet area associated with eyebrow ptosis after blepharoplasty with excessive muscle resection

44.3 Alternative Methods

Facial plastic surgeons must have access to other alternatives in order to address specific problems such as asymmetries resulting from facial paralysis or lateral descent of the eyebrow, and in order to offer solutions to those patients who cannot, or will not, undergo a surgical intervention.

Direct resection of an ellipse of skin at the tail of the eyebrow allows for a precise correction of asymmetries resulting from facial paralysis, since it not only repositions the brow but also provides an approach for suspension to the periostium of the orbicularis oculi. In lifting the lateral portion of the brow, the skin resection is performed over the temporal area taking an ellipse of scalp skin. The amount of tissue to be resected must be carefully assessed in order to avoid asymmetries and create the smallest possible shortening of the sideburn.

The use of botulinum toxin has become one of the most widely used cosmetic procedures in facial plastic surgery. With a good knowledge of the forces exerted by the muscle groups of the upper third of the face, it is possible to achieve excellent results of brow tail repositioning and “crow’s feet” elimination. Occasionally, botulinum toxin can be used before endoscopic forehead lift to weaken the depressor muscles and help the frontalis muscle with brow elevation [9].

Several suspension methods using subcutaneous sutures and anchoring devices have been designed to improve long-term outcomes, although with variable results. Overall, nonabsorbable materials tend to extrude and produce granulomas and, for this reason, they have lost popularity.

Fig. 44.5 Distance is measured from the lateral canthus, the pupil at the medial canthus to the lower edge of the eyebrow and asymmetries are recorded

44.4 Anatomy

From superficial to deep, the following layers are found in the forehead: skin, subcutaneous cellular tissue, aponeurotic galea (enveloping the frontalis muscle), lax areolar tissue, and periosteum. Periosteum and galea meet approximately 1 cm above the orbital rim.

In the forehead, the frontalis is the only muscle that elevates the eyebrow. This muscle proceeds upward and backward along with the occipital muscle

through the attachment of its aponeurotic envelope. With no bone attachments, this muscle inserts into the skin of the brow after crossing the orbicularis oculi. Its multiple insertions on the forehead dermis give rise to the characteristic horizontal lines that develop as time goes by.

The procerus and corrugator supercilii muscles are the eyebrow depressors. They act on the head of the eyebrow, while the orbicularis of the lids acts on the lateral two-thirds of the eyebrow.

The procerus inserts onto the external aspect of the nasal bones and the upper nasal cartilages and on the intercilliary skin. When it contracts, it forms horizontal lines on the radix and pulls the head of the eyebrow down and inward.

The corrugator supercilli is located deep to the orbicularis and inserts onto the most medial portion of the supercilliary arch and the deep aspect of the eyebrows after crossing the orbicularis. When it contracts, this muscle forms the vertical lines of the glabella and pulls the head of the brow medially. It is the deepest muscle and the first we come across in endoscopic forehead lift. The depressor supercilii muscle emerges from the dermis and inserts just above the medial cantus. The orbicularis oculi muscle inserts on the orbital rim and then superiorly on the deep layer of the skin. When it contracts, its fibers become intertwined with the frontalis and the corrugator supercilli muscles, closing the palpebral fissure and lowering the eyebrow, creating the crow’s feet lines (Fig. 44.6).

b d c

a

Fig. 44.6 Forehead muscles that depress and elevate the eyebrows. (a) Orbicularis oculi. (b) Frontalis. (c) Corrugator supercili. (d) Procerus

Motor innervation is supplied by the frontal branch of the facial nerve arising from the parotid gland, deep to the superficial musculoaponeurotic system (SMAS). This branch crosses the zygoma over an area 2 cm anterior to the helix radix and 2 cm posterior to the lateral cantus and enters into the frontalis muscle divided into several separate branches. The most inferior branch goes to the corrugator supercili and depressor supercili muscles and to the medial region of the orbital portion of the orbicularis oculi.

This facial nerve runs along a plane deep to the superficial temporalis fascia (superficial fascia) inside the superficial temporal fat pad.

Deep to this superficial temporal fat pad is the superficial layer of the deep temporalis fascia (intermediate fascia) that is a continuation of the superficial zygomatic periosteum and of the masseteric fascia.

Deep to the intermediate fascia is the intermediate temporal fat pad and deep to it is the deep layer of the deep temporalis fascia (deep fascia) that extends into the periosteum of the deep aspect of the zygomatic arch.

The deep temporal fat pad lies between the deep fascia and the temporalis muscle.

Endoscopic forehead lift dissection is performed on the deep plane of the superficial termporal fat pad allowing the fat pad to protect the temporal branch of the facial nerve.

From there, the dissection may then proceed toward the middle third of the face, passing through the intermediate fascia toward the intermediate temporal fat pad. At this point, an incision is performed on the periosteum of the zygomatic arch, and the dissection then proceeds inferiorly (Fig. 44.7).

Consequently, the dissection is safe if performed along the subcutaneous plane or immediately superficial to the intermediate fascia. This is the usual plane for endoscopic forehead lift dissection. The deep temporalis fascia merges with the periosteum of the forehead at the level of the upper temporal line. In performing the dissection for endoscopic forehead lift, it is important to elevate the temporal portion and communicate this pocket with the frontal subperiosteal dissection. This is done from lateral to medial, creating a sufficiently large pocket to allow the continuation of the endoscopic procedure.

The sensory innervation to the forehead region is supplied, medially, by the ophthalmic branch of the trigeminal nerve through its supratrochlear and